The surgery part of dealing with a shoulder injury frequently gets a lot of attention from both the patient and the surgeon, but it is typically the postoperative rehabilitation plan and program that dictates success (or failure) after a shoulder surgery.

The write-up below explains the four different phases of postoperative rehabilitation after a shoulder surgery. It is cited from AAOS 2017 Postoperative Orthopaedic Rehabilitation Chapter 5 Shoulder Instability Repairs.

​​Phase I
In the immediate postoperative period, ROM is restricted. The primary goal of this phase is to prevent excessive scarring by allowing movement, but avoiding overaggressive motion that may compromise the surgical repair.
 
For example, after an anterior stabilization procedure, external rotation is restricted, as this may overstress the capsulolabral repair. Submaximal and subpainful isometric contractions are also initiated during phase 1 to stimulate muscle training, neuromodulate pain, and prevent muscle atrophy that occurs as a result of immobilization.
 
Phase II
During this intermediate phase, the emphasis is on advancing shoulder mobility. Active assistive range of motion (AAROM) and PROM exercises are incorporated into the treatment program. The patient’s ROM and capsular end feel will be used to determine the rate of progression. Patients with sufficient ROM and a soft end feel will be progressed slower than a patient with restricted ROM and a hard end feel.
 
Joint-mobilization techniques are used to restore normal motion and to correct asymmetric capsular tightness. If one side of the capsule is excessively tight, the humeral head may translate in the opposite direction away from the tightness.
 
In an overhead athlete, the clinician will progress the stretching exercises to allow the athlete to obtain “thrower’s motion” of approximately 115° ± 5° ER to allow the athlete to return to throwing. Strengthening exercises can be progressed to include isolated rotator cuff and scapular exercises. Performing dynamic stabilization drills, manual resistance training, and proprioceptive neuromuscular facilitation (PNF) drills with rhythmic stabilizations can enhance neuromuscular control and reestablish muscular balance. During this phase, the “thrower’s ten exercise” program is typically initiated.
 
Phase III
Phase III is designed to maintain shoulder ROM while improving strength, power, and endurance. Strengthening exercises are progressed to restore optimal sufficient muscle ratios. Muscular balance and dynamic joint stability should be achieved before initiating aggressive strengthening exercises, such as plyometrics or functional activities.
 
During this phase, eccentric muscle training and proprioceptive training are emphasized. Muscular endurance training also is performed to enhance dynamic functional joint stability and to prevent fatigue-induced subluxation. Plyometric training drills are utilized to increase the athlete’s functional mobility and to gradually increase the functional stresses onto the shoulder joint.
 
Overhead athletes are also progressed to the thrower’s ten program to improve strength, endurance, and posture during this period.
 
Phase IV
During this phase, the goal is to increase the functional demands on the shoulder and return the patient to unrestricted sport or daily activities. Upon successful completion of the rehabilitation program and achieving the desired goals, the patient may initiate a gradual return to sport activity in a controlled manner.
 
Other goals of this phase are to maintain the patient’s muscular strength, dynamic stability, and functional motion established in the previous phase. Therefore, the patient is encouraged to maintain a stretching and strengthening program on an ongoing basis to maintain optimal shoulder function.

With those caveats in mind, there are certain injuries that tend to occur in Crossfit athletes. Here’s some general injury information and additional specific information on how to spot them. 
 
When I see a patient in my clinic, I take his or her history, perform a physical exam, and frequently get imaging of the injured body part. I am first and foremost looking for what I think of as “red flag findings” – components of the history, imaging, or physical exam that cue me in to the possibility that a serious injury has occurred.  Injuries with red flag findings typically present as sudden injuries where the athlete was completely fine and then suddenly wasn’t. A “pop” may have been heard and/or felt.  At the time of the injury, there was a sudden inability to move or use the affected body part without extreme discomfort. Swelling typically occurs quickly. I frequently see patients with these stories who have persistent symptoms a couple of weeks out from their injury; I especially worry if their severe pain and disability has persisted despite rest and elevation and if they are having a hard time sleeping because of the pain. If you fall into this category after an injury, I highly recommend you see your health care provider to get checked out.
 
The most frequent injuries in Crossfit fall into the category of “overuse injuries.” These, too, can cause significant pain and disability, but they usually occur gradually over time. Typically, no one specific event or injury stands out to the patient; the pain and weakness just showed up and have not improved. Based upon my personal observation, the most frequently injured body part in terms of overuse Crossfit injury is the shoulder by far. Back pain/injury and knee injuries are next on the list.
 
Most Crossfit shoulder injuries involve irritation due to repetitive stress of the rotator cuff tendons, the biceps tendon, and the supportive ligaments of the shoulder. The shoulder joint is the most complex (and best :)) joint in the body with a lot of important structures that must all function perfectly together to work well without pain. If there is irritation or inflammation in the shoulder, this tends to set off a cascade of trouble that can result in persistent symptoms. Commonly, repetitive overhead lifting activities result in irritation and inflammation of the rotator cuff tendons (rotator cuff tendinitis or tendinopathy), irritation and inflammation of the bursa overlying the rotator cuff (subacromial bursitis), or a combination of the two. The biceps tendon is a structure separate from the rotator cuff that loves getting irritated with exercises common in Crossfit. Pull-ups, especially kipping ones, overhead squats, snatches, and shoulder-to-overhead moves like push presses can all irritate this tendon and cause persistent pain in the front of the shoulder. When any one of these conditions occur, the small muscles of the shoulder who have the responsibility of making the ball move perfectly within the socket sometimes fail to do so and even more pain occurs; this is termed “impingement syndrome.”
 
Sometimes the shoulder injury goes further than inflammation and is a tear of one of the structures.  The rotator cuff tendons can tear away from their insertions into the bone (rotator cuff tear) and the labrum, which is a ring of cartilage that deepens the cup of the shoulder and helps provide stability can detach from the cup (labral tear or SLAP tear). These tears can occur suddenly with a major injury or gradually over time as an accumulation of repetitive trauma.
 
Sometimes the inflammation is associated with structural changes of the shoulder joint, resulting in wearing away of the cartilage over each surface of the bone, the formation of bone spurs, and eventually even reshaping or wearing away of the bony surfaces of the joint. Both the ball and socket joint of the shoulder (glenohumeral osteoarthritis) or the smaller joint between the collarbone and the lateral edge of the shoulder (AC joint arthritis) can be affected. This is usually determined by looking at an X-ray.
 
Back pain or injury in Crossfit is also typically an overuse problem but the sudden onset of severe back pain can occur and needs to be assessed by your health care provider. Muscle strain, inflammation of the supporting ligaments of the spine, irritation of the discs between the vertebrae, and inflammation surrounding the small nerves exiting the spinal cord are all sources of back discomfort. Typically icing, active rest, and physical therapy/directed home exercise are the initial treatments of choice for pain that has come on gradually without a sudden severe injury.
 
Crossfit knee injuries generally fall into the overuse category and respond well to activity modification (going lighter on squats, modifying or avoiding lunges or one-legged exercises such as pistols), ice, elevation, and compression.  Although Crossfit does not generally involve a lot of agility movements (lateral, pivoting, or cutting motions), common Crossfit exercises like running, box jumps, double-unders, and squatting can all result in an injury to the cartilage of the knee most commonly seen in agility movements called a meniscus tear. This typically manifests as a focal, sharp pain in either the inside or outside part of the knee that occurs most frequently with twisting or flexion movements of the knee. Taking a break from exacerbating activities for a week or two is reasonable, but if these symptoms persist, it is best to seek evaluation with your health care provider.
 
There are a few other injuries that, while rare in general, tend to occur in the Crossfit population a little more frequently. Achilles tendon ruptures present suddenly and usually with a loud pop and a sharp pain in the back of the ankle.  The history usually includes a variant of “I thought someone hit me in the back of the ankle with a baseball bat.” Bounding box jumps are the most common cause of this injury and modifying box jump technique to include pausing at the bottom before jumping back on top of the box will reduce the risk of this injury. Distal biceps tendon ruptures at the elbow where the tendon tears from its insertion into the upper forearm occur when a sudden and sometimes unexpected force is applied to a flexed elbow, causing the elbow to extend against resistance. Again, a pop is typically felt and/or heard in the elbow and the contour of the biceps muscle appears different than the unaffected side. Both Achilles and distal biceps tendon ruptures are typically treated with surgery, especially in active patients, and if you suspect you may have one of these injury, seek medical evaluation sooner rather than later.
 
My parting thoughts on Crossfit are these: Crossfit is neither safer nor more dangerous than any other fitness or workout option as long as you make safe choices. Loading up the barbell before you are well-versed in lifting technique, trying to keep up with your friend who has been doing Crossfit for five years and you just started three weeks ago, ignoring pain or limitations in your range of motion for the sake of completing a workout “as prescribed/Rx” all set you up for the likelihood of sustaining an injury. My advice: build up slowly and work within your abilities while striving to get a little better each day. Enjoy the endorphins and happiness that accompany getting sweaty and elevating your heart rate, developing your strength and endurance, and growing healthier with each workout. Injury is not a foregone conclusion with Crossfitting as long as you make smart workout decisions. ​

*Note: this device is not yet available in the US.

​It seems incredibly rare for someone to dream up a completely novel treatment for a complex, challenging orthopedic problem and have that treatment be less invasive, less risky to the patient, cost less than the accepted existing standard treatments, and provide excellent results with little downside. Read below to find out about one such case.

There is a new device that is being utilized in Europe and Israel (currently not approved by the US FDA and not available for sale in the US) to treat patients with massive, irreparable rotator cuff tears. Clinical trials are currently underway in the US with the hope that FDA approval will be forthcoming. This device is the InSpace balloon. I learned about this new device while attending a recent international conference on shoulder surgery; I have no affiliation with the device or its inventors/owners, I just think it sounds incredibly innovative, promising, and brilliant and I really wish I had thought of it :).

​Clinical trials are currently underway in the US.

​The main focus regarding sports equipment safety is generally helmets. Other important protective equipment includes shoulder pads, chest protectors, shin guards, and protective eyewear; these also require proper fit, maintenance, and replacement when necessary

• It is important to note that there is no concussion-proof helmet
• Helmets protect your athlete from a serious brain or head injury

 
The CDC website is an excellent resource for information on helmet safety:
 
There are specific helmet fact sheets for specific sports:

• Baseball – Batters Helmets and Catchers Helmets
• Bike Helmets
• Equestrian Helmets
• Football Helmets
• Hockey - Hockey Helmets and Hockey Goalie Helmets
• Lacrosse Helmets
• Skateboard Helmets
• Ski Helmets
• Snowboard Helmets

 
The CDC website also has a link to download the free CDC HEADS UP Concussion and Helmet Safety app

• Helps teach parents and coaches how to spot a possible concussion and what to do if you think your child or teen has a concussion or other serious brain injury
• The app includes a 3D helmet fit feature that teaches about proper helmet fit, safety, and care​

Important Helmet Considerations:

​
Helmets should be cleaned regularly

• Warm water and a mild detergent
• Do not soak any part of the helmet
• Avoid high heat
• Do not use strong cleaners

Should be checked regularly for damage

• Do NOT use a cracked or broken helmet or a helmet that is missing any parts
• Check for missing or loose padding before the start of the season and regularly

 
Protect the helmet

• Don’t sit or lean on it
• Store it at room temp and not in a car  

Know when to replace a helmet

• This depends on wear and tear
• There may be a sticker on the helmet that says it should not be reconditioned and may say how long it can be used

Disclaimer: I am an avid runner and I admit to cherry-picking scientific research to advance the argument that running is AWESOME :).

I recently read a really interesting article by Gretchen Reynolds that shared new research findings regarding the benefits of running.  I have summarized the article below: 

I have a lot of patients who come to me with the worry that running ruins knees and is dangerous.  They question whether they should continue down the destructive path or transition to something lower impact and safer like the elliptical trainer.

I am happy to report that a new study finds that running may actually benefit the knee, improving the biochemical environment inside the knee to keep things working (running :)) smoothly.

A popular argument is that running is dangerous to knees: the cumulative effects of impact on the knee from running inevitably results in slow wear and tear of the cartilage cushion of the knee, resulting in damage to the joint resulting in arthritis.  

Thankfully, there is little evidence to support this argument and a growing body of evidence argues the contrary: epidemiological studies of long-term runners show that they are less likely to develop knee osteoarthritis than people who don't run.

Scientists posit that running may protect the knee because running is associated with relatively low body mass and carrying less body mass is known to reduce the risk of knee osteoarthritis.  Some researchers question whether running may have a more directly positive impact on knee joints, perhaps by impacting the workings of various cells within the knee.

Researchers at Brigham Young University sought to find out the answer by recruiting 15 female and male runners under 30 years old without a history of knee injury or arthritis.  The goal was to study people with healthy knees in order to better isolate running's impact on otherwise normal joints.   The volunteers had blood drawn from an arm and then had a small amount of fluid (termed "synovial fluid") removed from their right knee.  This fluid is a naturally-occurring fluid within joints that reduces friction through lubrication.  Healthy knees contain only a small amount but arthritic or otherwise unhealthy knees contain much greater quantities of synovial fluid.

Next, the volunteers were transported via wheelchair to the university biomechanics lab where they either sat quietly for 30 minutes or ran on a treadmill at their preferred running speed for 30 minutes.  Following their respective 30 minutes of sitting or running, they were again wheeled to the clinic where blood and synovial fluid draws were again performed.  Each volunteer completed both a sitting and a running session on separate days.

Once the blood and synovial fluid draws were complete, the researchers investigated a variety of substances within the young runners' blood and synovial fluid.  They focused particularly on molecules associated with inflammation because low-grade inflammation has been associated with the development and progression of arthritis.

The researchers looked for changes in the levels of several types of cells that are known to either increase or diminish the amount of inflammation within the knee.  They also looked for changes in the level of a substance known as cartilage oligomeric matrix protein (COMP) which is often used as a marker of incipient or worsening arthritis.  Compared to healthy knees, knees with arthritis can have about five times as much COMP in their synovial fluid.  

Unfortunately, it turned out to be technically difficult to safely extract much synovial fluid from these healthy knees and the scientists wound up with complete numbers in only six out of the thirty runners.

But that being said, the data were interesting and consistent.  In nearly every case, the runners' knee showed substantially lower levels of two types of cells that contribute to synovial inflammation, compared to their baseline levels.  The runners showed a shift in their COMP: they had more of the substance in their blood and less in their synovial fluid.   It seemed that running had squeezed the inflammatory substance out of their knee and instead into the blood.

Meanwhile, sitting resulted in slightly increased levels of COMP inside the knee and also raised the concentration of one of the inflammatory molecules.

Overall, these findings indicate that a single 30-minute session of running changes the interior environment of the knee, reducing inflammation and diminishing the level of a marker of arthritis.  

An unexpected finding of the study is that sitting for 3o minutes also changes the interior environment of the knee, a finding that the authors of the study had not expected.  Sitting seems to make the knee more biochemically vulnerable to later disease.

The lead author, Dr. Robert Hyldahl, professor of exercise science at BYU, notes that this study is very small and short-term.  He would prefer to repeat it on a much larger scale "once we figure out how to get more synovial fluid" safely from healthy knees.

Dr. Hyldahl and his colleagues also hope to study longer running distances and various paces to see how these variables affect change within the knee.  They also hope to recruit older and injured runners whose knees might have begun to respond fundamentally differently to the act of running than the joints of healthy people in their 20s.

Despite the limitations of the study, the lead author notes that the findings argue that moderate amounts of running are not likely to harm healthy knees and likely offer protection against joint damage.

I want to share a terrific article explaining the benefit of high-impact exercise.  I have had countless patients ask me if it is best to continue running and participating in other high-impact exercises or if it would be better to cut back and strictly embrace more gentle types of exercise; this article certainly makes a case for the former and I talk with my patients frequently about its findings and recommendations.
This article by Gretchen Reynolds provides a compelling argument as to why we should continually participate in exercises that jar our bodies.   I've summarized its content below.

A study by researchers at the University of Bristol found that athletes who experienced impacts of 4.2 G's or greater had significantly sturdier hipbones than athletes who did not participate in exercises that reached that threshold.  Exercises that generate enough force to achieve 4.2 G's include running a 10-minute mile or jumping up onto and off of a box that is 15 inches or higher.  This study compels me to encourage all of my patients, especially my patients who are in their forties, fifties, and beyond, to pound the ground in order to strengthen their bones and (hopefully) prevent fragility fractures such as hip fractures.
Another study found that after four months of high-impact jump training (simply hopping in place), hip bone mineral density (BMD) could be improved in premenopausal women by jumping 10 or 20 times, twice daily, with 30 seconds of rest between each jump.  This is exciting news for anyone looking to optimize their bone health and prevent injury  organically through exercise.
As always, it is best to consult your physician before initiating a new exercise program and certainly this is the case with older individuals seeking to start a high-impact exercise program as the stress required to improve bone health may be too much for certain individuals' bodies and bones to handle, at least initially.  This caveat also applies to those of us with joint troubles including arthritis.

​
I want to discuss  a condition that I frequently diagnose and treat in my clinic and for which I have a particular fondness and focus within my orthopaedic surgery practice: shoulder arthritis.  I have many patients who come to see me with shoulder pain who are a.) very surprised to find out that they have shoulder arthritis and b.) are even more surprised to find out that there are excellent treatment options available to treat shoulder arthritis.
 
The shoulder joint (termed the “glenohumeral joint” in medical nomenclature) is the third-most common large joint affected by degenerative joint disease (knee and hip arthritis are more common).  There are multiple types of shoulder arthritis and all of these ulitmately result in a wearing away of the "cushion" of the joint, the smooth outer covering of the bone known as the articular cartilage.  As the cartilage wears away, the protective space within the shoulder joint narrows and the cartilage becomes rough and frayed and eventually wears completely away.  This results in the bones of the shoulder joint rubbing against each other, causing pain.  Because of the increased pressure on the surfaces of the bone, there can be structural changes that gradually occur within the shoulder including the formation of bone spurs (termed "osteophytes") and changes of the shape of bones of the shoulder.  Although there is no cure for shoulder arthritis, there are many treatment options available.  The goals for treatment are to manage pain and to allow you to remain active.  

​
​Pain is the most common symptom of arthritis of the shoulder and it is exacerbated by activity.  The natural progression is for the pain to worsen over time, although how rapidly the pain progresses is unique to each patient.  With shoulder arthritis, the pain is typically centered deep within the shoulder and may intensify with weather changes.   Patients typically describe their pain as a deep ache, which worsens with activity. 
 
Other symptoms include limited range of motion, sensations of clicking, grinding, and or snapping with movement of the shoulder, and, as the disease process progresses, pain at night which causes significant difficulty with sleep.

Initial treatment of shoulder arthritis is nonsurgical and includes options such as:

• Rest or change in activities to avoid exacerbating the pain.   This also includes changing how you move your shoulder to accomplish specific tasks to minimize discomfort
• Physical therapy to maximize range of motion
• Nonsteroidal anti-inflammatory medications (NSAIDS) to reduce pain and inflammation.  These medications can have significant side effects and should be taken with food.  They can irritate the stomach lining and cause internal bleeding.  If you have a history of ulcers or other GI problems, are taking blood thinning medication, or have cardiac disease, you should consult your doctor before taking over-the-counter NSAIDS
• Corticosteroid injections performed by me directly into your shoulder joint.  Although the results, which can be dramatic in terms of reduction of pain and inflammation, are typically temporary, injections may play an important role in initially managing shoulder arthritis
• Icing your shoulder 20 minutes two to three times a day to reduce pain and inflammation
• Moist heat, particularly in the morning
• Special prescription medications for patients with a specific type of shoulder arthritis called rheumatoid arthritis
• Dietary supplements, such as glucosamine and chondroitin sulfate (with the caveat that the FDA does not test dietary supplements, there is little scientific evidence supporting the use of glucosamine and chondroitin sulfate, and there is the possibility of negative interactions with other medications)

If your pain from your shoulder arthritis is not adequately addressed with the nonoperative treatments above then surgery is the next treatment step and usually consists of shoulder replacement surgery.  There are multiple different types of replacements available and I will spend a lot of time talking with you about which option is the most appropriate to address your specific situation.
 
Briefly, the replacement surgery options include:

• Hemiarthroplasty:  Only the head of the humerus (ball of the shoulder) is replaced by an artificial component
• Total shoulder arthroplasty: Both the head of the humerus (the ball) and the glenoid (the cup of the shoulder joint) are replaced
• Reverse total shoulder arthroplasty: In this type of replacement, the cup of the shoulder is replaced with a ball and the ball of the shoulder is replaced with a cup.  This reversal of positioning allows patients with a particular type of shoulder arthritis called “rotator cuff tear arthropathy” to move the arm well despite not having a functional rotator cuff

 
If you are having shoulder pain, consider scheduling an appointment to find out what is causing your pain and the best treatment(s) for you.

 

​Up until today, I didn't give much consideration to how I, as an orthopaedic surgeon, could contribute to the discussion of how much is safe with regards to safe quantities of alcohol consumption.  The op-ed piece entitled "Drinking by Numbers," by Bonnie Tsui, published today in the New York Times Sunday Review section, changed that.

I found Ms. Tsui's article to be incredibly insightful and thought-provoking and it immediately sparked me to examine my clinical practice and how I counsel my patients with regards to alcohol consumption.  As an orthopaedic surgeon, I have an inherent vested interest in my patients' bone health and I frequently advise my patients to engage in weekly or biweekly impact exercise to maximize bone density and strength (for an excellent general article on the topic of the importance of high-impact exercise, click here).  Counseling regarding alcohol consumption is relevant in my practice because alcohol can (and frequently does) lead to impaired balance, compromised decision-making, and incredibly entertaining but risky dance moves, among other things.  These, in turn, lead to orthopaedic injuries such as shoulder fractures and broken hips.  Instead of yet another scientific article that merely facilitates further confusion as to whether or not alcohol consumption is healthy or unhealthy, Ms. Tsui's nuanced article examines the motivations behind alcohol consumption and provides an extremely useful suggestion as to how one can determine a safe number of alcoholic beverages to consume:

"Nothing is as important as something. Nothing is the reference point from which we can judge all else. The numerical middle is different for everyone, but perhaps that’s the point. Because my number is two and yours may be one and his might be five, the most relevant number to us all is zero.Maybe the only way to think about drinking by numbers is not to obsess over how much is too much, but to be acquainted with what zero feels like — that is, to come back to zero often enough to understand the relative value of our numbers. The reset helps us see those numbers for what they are."

This advice recognizes that everyone's tolerance is different and does not attempt to give a hard and fast number for a "safe" quantity of alcohol.  Instead, it advocates awareness and thoughtfulness, as well as moderation.  I wholeheartedly agree.

April is Youth Sports Safety Month.  Take a look at my blog post on AOSSM's STOP Sports Injuries website for tips to help maximize the benefits of sports for your children while minimizing the risk of injury:

http://www.stopsportsinjuries.org/STOP/Blog/Posts/Five-Tips-for-a-Safe-Youth-Sports-Experience.aspx

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